Summary On 08 April 2006, the shuttle tanker Kometik, in ballast condition, was at anchor in Conception Bay, Newfoundland and Labrador. A welder and a crew member were performing welding repairs in cargo tank No.5 starboard when, at approximately 1113Newfoundland daylight time, an explosive vapour mixture was ignited in the cargo tank. The welder escaped from the tank with serious injuries and the body of the crew member was recovered by shore-based firefighters later that afternoon. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Description of the Vessel The vessel is a twin-skeg, twin-screw shuttle tanker with 12cargo tanks, two slop tanks, 13segregated ballast tanks, and a bow-loading system on the forecastle deck. The vessel is fitted with a dynamic positioning system that operates two controllable-pitch propellers (CPP) in the bow, two aft, and two Becker-type high-lift rudders. History of the Voyage On 04 April 2006, after discharging a cargo of Hibernia crude oil at Whiffen Head on Placentia Bay, N.L., the Kometik proceeded to anchorage in Conception Bay. In preparation to effect repairs of a deck crack in way of the MARPOL line2 above cargo oil tank (COT) No.4 port, and to inspect all cargo oil tanks to determine if any repairs in those tanks would also be required, all 12COTs were washed, purged, and gas freed during the passage. The vessel was also advised that it would be required to arrive at Hibernia at 0600 on April 11. The Kometik anchored in Conception Bay on April5 at 20243; an approximate track of the voyage is shown in Figure1. Figure1.Approximate track of the Kometik To utilize this extra time while at anchor in Conception Bay, it was decided by the ship's senior officers and confirmed by the shore-based superintendent that tankers would carry out as many repairs and inspections as possible in the time allowed. Under the continuous supervision of the chief officer (C/O), all 12cleaned and gas-freed COTs were inspected for damage. On the morning of April 6, a welder and a marine chemist4 boarded the vessel. As the welder performed minor repair work on and about the main deck, the chemist tested the atmosphere in COT No.4 port and starboard, issuing a certificate of gas hazard (a gas-free certificate), valid for those two tanks only, at 1300. The C/Oalso completed the enclosed space entry and the hot work permits as contained in the vessel's shipboard safety manual (SSM). Crew members were subsequently sent into the tank to erect scaffolding and safety lines so the welder could make priority repairs inside the tank (on the underside of the deck). The chemist left the vessel the same day. At 1400, the C/O tested COT No.5 port and starboard with a gas-detector multi-meter; both tanks were found to have 0percent of the lower explosive limit (LEL) of methane. The C/Oand another crew member entered the tanks for inspection at 1910and found some damage. At approximately 2200, the master phoned the superintendent-tankers and informed him of the findings. On April 7 at 1345, the C/O again tested the atmosphere of cargo tanks Nos.5 port and starboard and both were found to still have 0percent LEL of methane. The C/O and a crew member, the two of them now accompanied by the superintendent - tankers, re-entered the tanks to more closely ascertain the extent of repair work required. Cracks on brackets used to secure the cargo pipe lines in both cargo tanks were noted and provisions were made for a second welder to board the vessel the next day to assist with repairs. Later that evening, due to an unfavourable weather forecast, the master decided to move the vessel to deeper water. Furthermore, it was decided to finish the repair work and have shore workers and their equipment put ashore as soon as possible so that the vessel could depart by noon on April9. At 0800 on April 8, a safety meeting was held during which all relevant permits pursuant to the company's safety management system were issued.5 At 0824, two crew members entered cargo tank No.6 starboard to repair a broken hydraulic line that controlled the stripping line valve for tank No.5 starboard. A few minutes later, the welder, the C/O, and a crew member entered tank No.5 port to effect welding repairs. At 0929, the two crew members working in tank No.6 starboard had completed their repairs and requested that the stripping line valve for No.5 starboard be cycled to bleed air from the newly repaired hydraulic line. The valve was activated from the remote control station on the bridge and it took 19seconds to cycle the valve from closed to open to closed again. The crew members exited the tank shortly after. Ship's records indicate that this valve was again cycled at 1007and that it took 15seconds. After a coffee break, the welding equipment was moved from tank No.5 port to No.5 starboard. Although the tank atmosphere was not tested by anyone on the morning of the accident, a crew member and a second welder entered that tank. Neither person carried an emergency breathing apparatus, nor was there ongoing gas monitoring as required by the shipboard safety manual. No safety harnesses or recovery safety lines were worn. A fire hose was lowered into the cargo tank, but it was not pressurized. A tarp was laid down as a spark suppressor; however, it was not wetted down as indicated in the "Special Conditions/Precautions" section of the hot-work permit that had been issued at that morning's safety meeting. At about 1113, a loud noise was heard and thick black smoke was seen coming from cargo tank No.5 starboard. A few seconds later, the injured welder emerged on deck from the manhole at the tank's forward end. He was taken to the ship's hospital and later evacuated to a hospital ashore. The ship's fire parties were mustered and they extinguished the fire within 15minutes. During this time, the crew member still in the tank was in constant radio communication with the deck crew. Subsequently, the intense heat coming from the tank prevented anyone from entering, and no further communication was received from the trapped crew member. The Conception Bay South Volunteer Fire Department boarded the vessel at 1255and, with assistance from the ship's crew, recovered the crew member's body at 1440. A search and rescue (SAR) helicopter was used to transport the body to the local hospital. Vessel Certification The Kometik carried all appropriate certificates for a vessel of its class and voyage. The vessel also complied with the requirements of the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code). Personnel Certification The master and officers of the Kometik held certificates that were valid for the vessel's class and service. All officers and crew had received Marine Emergency Duties training and had participated in an appropriate in-house training program consistent with the company's safety management system and Transport Canada's requirements, according to the position held on board. Personnel History The master had sailed on oil tankers since 1986, moving up from ordinary seaman (OS) to master and serving as master on two previous vessels. He had served as a C/O with the operating company since March2000 and as master of the Kometik since June2001. The C/O graduated from the Fisheries and Marine Institute's Nautical Program in 1996 and had sailed on a variety of vessels including oil tankers. He began serving on the Kometik in May2000, as third officer and then second officer. He had been serving as C/Osince December2002 and held a Master Mariner's Certificate issued 22December2003 and valid until 21December2008. Injuries to Persons The crew member trapped in the cargo tank died as a result of smoke inhalation. The welder suffered extensive burns and lung damage. Damage to Vessel There was no structural damage to the vessel. Recovery operations, however, caused minor damage to heating coils at the bottom of the cargo tank. Work Planning Initial activities were carried out respecting standard procedures (for example, hiring a marine chemist to test COT No.4 port and starboard). As the operations progressed, activities such as the repairs to pipe support brackets in two other tanks (COT No.5 port and starboard) were added to the operations and carried out using the resources at hand. The C/O tested the atmosphere of all tanks using a hand-held meter prior to tank inspection. He also used this method for verifying safe entry into tanks requiring internal repairs. However, a marine chemist was not recalled after the initial visit on April 6 to certify those tanks in which hot work was to be done as "gas free." The additional work was undertaken without the following: an overall plan for coordinating the individual activities; a risk assessment of the overall activity; and an assessment of the work/crew requirements. The approaching bad weather added an element of time pressure, with the crew required to complete the work so the vessel could leave the area by noon on April9. Tank Maintenance Cargo oil tanks are normally cleaned and gas-freed for inspection on an annual basis. However, it may be necessary to enter a tank at any point - to conduct, for example, necessary repairs to valves, hydraulic control lines, actuators, etc. When this occurs, the opportunity is taken to complete a tank inspection. The procedure for cargo tank cleaning prior to an entry is a crude-oil wash (during the discharge) followed by a water wash. The time required for a full tank wash/gas-freeing is generally 48hours. The cargo tank must first be purged by introducing inert gas (IG) by way of an IGsystem. Then, when oxygen levels are appropriate, the tank is water-washed. Gas-freeing occurs by blowing clean air into the tanks using the IGblowers. Workload On a shuttle tanker such as the Kometik, the vessel's short runs necessitate quick turnarounds and frequent cargo-handling operations. These take place on a 24-hour basis and require long periods of supervision. The C/O is responsible for all cargo-handling operations as well as directing and supervising the deck department. He did not stand a bridge watch. Two other deck officers are designated as watchkeepers. Two vessels6 that were similar, but which travelled to the United States (U.S.), had an additional qualified deck officer on board to assist with vessel operations, in accordance with U.S. regulatory requirements. Tank cleaning is also an activity that requires close supervision by a senior crew member. Although it occurs infrequently, it is nonetheless an extensive, safety-sensitive procedure which normally spans both day and night shifts over several days. Since beginning that particular trip on April 3, the C/O had been almost continuously involved in cargo operations and tank cleaning, in addition to his duties directing and supervising the deck department's daily work and monitoring repairs being performed by shore contractors. Fatigue The C/O normally worked day shifts of 12 hours' duration. On his first day of work after joining the vessel on April 3, he took a short nap in anticipation of an extended work schedule, and then worked through the night to support cargo-discharge operations. The following morning, he slept for approximately six hours before working the remainder of the day shift. As on subsequent days, he was involved in vessel operations until the late evening. He had disturbed sleep for the next two nights, and was suffering flu-like symptoms. He was taking cold medication that included a stimulant and he was also taking a prescription antidepressant. For the two nights preceding the accident, his sleep was less disturbed and more in accordance with his normal sleeping hours. Tables in AppendixA illustrate the C/O's sleep history. All times are estimated, based on reports from the C/O and a review of the relevant logs. The Canada Labour Code states that it is the duty of both the employer and the employee to manage numerous health and safety issues.7 Additional Canadian regulations in effect at the time explicitly spelled out the frequency and duration of rest periods for employees.8 In the days leading up to the occurrence, the C/O met the minimum requirement of six hours of rest per individual 24-hour period; however, he did not meet an additional requirement for a minimum of 16 hours of rest over the 48-hour period prior to the event. Quality and Safety Management System The ISM Code was adopted by the IMO in 1993and provides an international standard for the safe management and operation of ships and pollution prevention. Governments are required to take necessary steps to safeguard the shipmaster in the proper discharge of his responsibilities in these areas. The code also recognized the need for management to be appropriately organized to respond to the needs of those on board to achieve and maintain high standards of safety and environmental protection. In practice, a ship is issued a safety management certificate (SMC) and its operating company is issued a document of compliance (DOC) once the systems in place have been audited by an accredited organization. The Kometik engaged wholly in domestic trade but was nonetheless a convention vessel compliant with the ISM Code that came into force on 01July1998. The operating company developed a quality and safety management system (QSMS) to meet the requirements of the ISMCode. Accordingly, classification society Det Norske Veritas issued a DOC to the operating company, and the American Bureau of Shipping issued an SMC to the Kometik. The SMC is subject to renewal every five years, with an interim external audit between the second and third anniversary dates of the SMC and an annual verification of the company's DOC through external audits. In accordance with the ISM Code, the Kometik's SSM includes procedures for safe working practices including gas-freeing, enclosed-space entry, hot work, and the danger tag/lockout system.9 Procedures were also in place to address identified operational risks and safety-critical equipment and systems. Combustible Gas Meters The instrument used on board the Kometik was a hand-held, battery-powered gas meter. It is used for sampling the ambient oxygen concentration and for detecting toxic or flammable materials that may be present in a cargo tank. Information saved in the data log, including time and readout/percentage/parts per million, can be downloaded to a computer. The instrument is accurate to 3percent of the LEL. The built-in memory of the instrument shows monitoring activity only during the time the crew was in the COTNo.5port. Personal Protection Equipment In this instance, the welder, a contract employee hired to carry out the hot work, wore coveralls made from 100 per cent cotton/denim. This heavy, tightly woven fabric has natural flammability resistance at low temperatures but does not provide protection against high-temperature flash fires.10 On top of the denim coveralls, the welder wore a pair of the ship's disposable polyethylene coveralls. Neither of these items was treated to enhance flame-retardant properties, and the disposable coveralls were contaminated with petroleum products from the tank's oily residue. By the time the welder emerged from the tank, these disposable coveralls had been almost completely consumed. The crew member who was assisting the welder was wearing 100 per cent cotton coveralls with reflective patches. This was standard protective equipment issued by the company. All fibres- natural or manufactured- have their own unique durability and flammability characteristics. Fabrics made from cellulose fibres tend to be more durable, but exhibit poor flammability characteristics. Fabrics produced from protein fibres, on the other hand, are less durable, but demonstrate good flammability properties. Manufactured synthetic fabrics, although durable, are generally heat sensitive. Modern textiles are often produced by combining natural and manufactured fibres to obtain the flammability properties of one and the durability characteristics of the other. Requirements for uniform/protective clothing are referenced in the Marine Occupational Safety and Health Regulations and also in the Safe Working Practices Regulations, which state: Moreover, the regulations state: The regulations offer no guidance as to what fabrics constitute suitable uniform/protective clothing. However, Canadian General Standards Board standard CAN/CGSB-155.20-2000, Workwear for Protection Against Hydrocarbon Flash Fire, provides the minimum requirements for performance of workwear for protection against such a hazard. The standard also provides guidance for the warnings and information to be included on the label to be affixed to the workwear.13